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Delayed sleep phase syndrome
| Image = | Caption = | DiseasesDB = | ICD10 = G47.2| ICD9 = | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | }} Delayed sleep-phase syndrome (DSPS), also known as delayed sleep-phase disorder, is a chronic disorder of sleep timing. People with DSPS tend to fall asleep at very late times, and also have difficulty waking up in the morning. Often, people with the disorder report that they cannot sleep until early morning, but they fall asleep at about the same time every "night", no matter what time they go to bed. Unless they have another sleep disorder such as sleep apnea in addition to DSPS, patients can sleep well, and have a normal need for sleep. Therefore, they find it very difficult to wake up in time for a typical school or work day if they have only slept for a few hours. However, they sleep soundly, wake up spontaneously, and do not feel sleepy again until their next "night" if they are allowed to follow their own late schedule, e.g. sleeping from 4 a.m. to noon. The syndrome usually develops in early childhood or adolescence, Dagan Y; Eisenstein M Circadian rhythm sleep disorders: toward a more precise definition and diagnosis. Chronobiol Int 1999 Mar;16(2):213-22 and sometimes disappears in adolescence or early adulthood. It can be to a greater or lesser degree treatable, but cannot be cured. DSPS was first formally described in 1981 by Dr. Elliot D. Weitzman and others at Montefiore Medical Center.* It is responsible for 7 -10% of cases of chronic insomnia. However, as few doctors are aware of its existence, it often goes untreated or is treated inappropriately. DSPS is frequently misdiagnosed as primary insomnia or as a psychiatric condition. Definition According to the International Classification of Sleep Disorders (ICSD), the key characteristics of DSPS are: The following features of DSPS distinguish it from other sleep disorders: *People with DSPS have at least a normal - and often much greater than normal - ability to sleep during the morning, and sometimes in the afternoon as well. In contrast, those with chronic insomnia do not find it much easier to sleep during the morning than at night. *People with DSPS fall asleep at more or less the same time every night, and sleep comes quite rapidly if the person goes to bed near the time he or she usually falls asleep. Young children with DSPS resist going to bed before they are sleepy, but the bedtime struggles disappear if they are allowed to stay up until the time they usually fall asleep. *DSPS patients can sleep well and regularly when they can follow their own sleep schedule, e.g. on weekends and during vacations. *DSPS is a chronic condition. A diagnosis of DSPS is generally not given unless symptoms have been present for at least a month. Attempting to force oneself through 9–5 life with DSPS has been compared to constantly living with 6 hours of jet lag. Often, sufferers manage only a few hours sleep a night during the working week, then compensate by sleeping until the afternoon on weekends. Sleeping in on weekends, and/or taking long naps during the day, gives people with the disorder relief from daytime sleepiness but also perpetuates the late sleep phase. People with DSPS tend to be extreme night owls. They feel most alert and say they function best and are most creative in the evening and at night. DSPS patients cannot simply force themselves to sleep early. They may toss and turn for hours in bed, and sometimes not sleep at all, before reporting to work or school. By the time DSPS patients seek medical help, they usually have tried many times to change their sleeping schedule. Failed tactics to sleep at earlier times may include relaxation techniques, early bedtimes, hypnosis, alcohol, sleeping pills, dull reading, and home remedies. DSPS patients who have tried using sedatives at night often report that the medication makes them feel tired or relaxed, but that it fails to induce sleep. They often have asked family members to help wake them in the morning, or they have used several alarm clocks. As the syndrome is most common in adolescence, it is often the patient's parents who initiate seeking help, after great difficulty waking their child or teenager in time for school. As of May 2007, the new International Classification of Sleep Disorders has changed the name from Delayed Sleep Phase Syndrome to Delayed Sleep Phase Disorder. Prevalence Using the strict ICSD diagnostic criteria, a random study in 1993 of 10,000 adults in Norway estimated the prevalence of DSPS at 0.17%. Schrader H, Bovim G, Sand T. The prevalence of delayed and advanced sleep phase syndromes. J Sleep Res. 1993 Mar;2(1):51-55. A similar study with 1525 adults in Japan estimated its prevalence at 0.13%. Yazaki, Mikako et al. Demography of sleep disturbances associated with circadian rhythm disorders in Japan Psychiatry and Clinical Neurosciences Volume 53 Issue 2 Page 267 April 1999 Other studies have indicated that the prevalence of DSPS among adolescents is as high as 7%. American Academy of Sleep Medicine International Classification of Sleep Disorders, Revised Edition 2001. Physiology DSPS is a disorder of the body's timing system - the biological clock. Individuals with DSPS might have an unusually long circadian cycle, or might have a reduced response to the re-setting effect of light on the body clock. People with normal circadian systems can generally fall asleep quickly at night if they slept too little the night before. Falling asleep earlier will in turn automatically advance their circadian clocks. In contrast, people with DSPS are unable to fall asleep before their usual sleep time, even if they are sleep-deprived. Research has shown that sleep deprivation does not reset the circadian clock of DSPS patients, as it does with normal people.Uchiyama, Makoto et al. Poor recovery sleep after sleep deprivation in delayed sleep phase syndrome Psychiatry and Clinical Neurosciences Volume 53 Issue 2 Page 195 - 197 April 1999 People with the disorder who try to live on a normal schedule have difficulty falling asleep and difficulty waking because their biological clocks are not in phase with that schedule. Normal people who do not adjust well to working a night shift have similar symptoms. People with the disorder also show delays in other circadian markers, such as melatonin-secretion and the core body temperature minimum, that correspond to the delay in the sleep/wake cycle. Sleepiness, spontaneous awakening, and these internal markers are all delayed by the same number of hours. Non-dipping blood pressure patterns are also associated with the disorder when present in conjunction with socially unacceptable sleeping and waking times. In most cases, it is not known what causes the abnormality in the biological clocks of DSPS patients. DSPS tends to run in families and a growing body of evidence suggests that the problem is associated with the hPer3 (human period 3) gene.Evolution of a length polymorphism in the human PER3 Gene, Nadakarni et al.JOURNAL OF BIOLOGICAL RHYTHMS / December 2005. There have been several documented cases of DSPS and non-24 hour sleep-wake syndrome developing after traumatic head injury. Boivin, D.B. et al. Non-24-hour sleep–wake syndrome following a car accident Neurology 2003;60:1841-1843 Quinto, Christine et al. Posttraumatic delayed sleep phase syndrome Neurology 2000;54:250 There have been a few cases of DSPS developing into non 24-hour sleep-wake syndrome, a more severe and debilitating disorder in which the individual sleeps later each day. Diagnosis DSPS is diagnosed by a clinical interview, actigraphic monitoring and/or a sleep log kept by the patient for at least three weeks. DSPS is frequently misdiagnosed or dismissed. It has been named as one of the sleep disorders most commonly misdiagnosed as a primary psychiatric disorder. Stores, Gregory. Misdiagnosing sleep disorders as primary psychiatric conditions. Advances in Psychiatric Treatment 2003, vol.9, 69-77 DSPS is often confused with psychophysiological insomnia, depression, psychiatric disorders such as schizophrenia, ADHD or ADD, other sleep disorders, or willful behaviour such as school refusal. Practitioners of sleep medicine point out the dismally low rate of accurate diagnosis of the disorder, and have often asked for better physician education on sleep disorders.Dagan, Yaron M.D., D.Sc.; Ayalon, Liat Ph.D. Case Study: Psychiatric Misdiagnosis of Non-24-Hours Sleep-Wake Schedule Disorder Resolved by Melatonin. Journal of the American Academy of Child & Adolescent Psychiatry. December 2005;44(12):1271-1275. Impact on patients Lack of public awareness of the disorder contributes to the difficulties experienced by DSPS patients, who are commonly stereotyped as undisciplined or lazy. Parents may be chastised for not giving their children acceptable sleep patterns, and schools rarely tolerate chronically late, absent, or sleepy students and fail to see them as having a chronic illness. By the time DSPS sufferers receive an accurate diagnosis, they often have been misdiagnosed or labelled as lazy and incompetent workers or students for years. Misdiagnosis of circadian rhythm sleep disorders as psychiatric conditions causes considerable distress to patients and their families, and leads to some patients being inappropriately prescribed psychoactive drugs. For many patients, diagnosis of DSPS is itself a life-changing breakthrough.Dagan, Yaron and Abadi, Judith Sleep-Wake Schedule Disorder Disability: A lifelong untreatable pathology of the circadian time structure. Chronobiology International 2001; Volume 18, Number 6 Pages: 1019 - 1027 Treatment Treatment for DSPS is specific. It is different from treatment of insomnia, and recognizes the patient's ability to sleep well while addressing the timing problem. Before starting DSPS treatment, patients are often asked to spend a week sleeping regularly, without napping, at the times when the patient is most comfortable. It is important for patients to start treatment well-rested. Treatments that have been reported in the medical literature include: *Light therapy (phototherapy) with a full spectrum lamp or portable visor, usually 10000 lux for 30-90 minutes in the morning. Sunlight can also be used. Light therapy generally requires adding some extra time to the patient's morning routine. It takes from a few days to two weeks to take effect, with occasional use thereafter to help maintain the schedule . Avoidance of bright light in the evening may also help. *Chronotherapy, which resets the circadian clock by manipulating bedtimes. It can be one of two types. The most common consists of going to bed two or more hours later each day for several days until the desired bedtime is reached. A modified chronotherapy (Thorpy, 1988) is called controlled sleep deprivation with phase advance, SDPA. One stays awake one whole night and day, then goes to bed 90 minutes earlier than usual and maintains the new bedtime for a week. This process is repeated weekly until the desired bedtime is reached. *A small (~1mg) melatonin supplement taken an hour or so before bedtime may be helpful in establishing an earlier pattern, especially in conjunction with bright light therapy at the time of spontaneous awakening. However, some suggest taking melatonin at sunset to mimic natural endogenous secretion of melatonin. Rather than taking melatonin as a sedative, it is used in this way as a natural way to reset the circadian clock. Side effects of melatonin may include disturbance of sleep, nightmares, daytime sleepiness and depression. The long-term effects of melatonin administration have not been examined and production is unregulated. In some countries the hormone is available only by prescription or not at all. In the United States and Canada, melatonin is freely available as a dietary supplement. *Cannabis has been successfully used as a sleeping aid to combat DSPS. Sleep onset is affected by the two primary cannabinoids, Δ9-Tetrahydrocannabinol (THC) dramatically increases melatonin production* and Cannabidiol (CBD) has been shown to be effective in helping insomniacs sleep* . Heavy cannabis use can lead to decreased levels of REM sleep and increased levels of slow-wave sleep along with reduced mental function the next morning however this is heavily dependent on dose, 5mg doses of THC and CBD have been shown not to have these effects* . Anecdotal evidence suggests that the Indica strain is particularly effective . *Some claim that large doses of vitamin B12 help normalize the onset of sleepiness, but little is known of the effectiveness of the treatment. *A treatment option which shows promise is Ramelteon, a recently-approved drug which in some ways acts as melatonin does. Production of ramelteon is as regulated as any other prescription medicine, so it avoids any possible problem of variable purity with melatonin supplements. *Modafinil is approved in the USA for treatment of Shift-work sleep disorder, which shares some characteristics with DSPS, and a number of clinicians are prescribing it for DSPS patients. However, modafinil does not deal with underlying causes of DSPS, it merely improves sleep deprived patient's quality of life. Taking modafinil less than 12 hours before the desired sleep onset time will actually exacerbate the symptoms by pushing back the sleep/wake cycle. *There has been one documented case in which a person with DSPS was successfully treated with trazodone.Nakasei, Shinji et al. Trazodone advanced a delayed sleep phase of an elderly male: A case report Sleep and Biological Rhythms Volume 3 Page 169 - October 2005 See Also: Phase response curve Once the patient has established an earlier sleep schedule, following highly regular sleep/wake times and practicing good sleep hygiene are essential. DSPS patients are counselled to not go to bed if they are not sleepy, as doing so generally does not result in earlier sleep times. They are also advised to avoid alcohol and caffeine before bedtime. With treatment, some people with DSPS can sleep and function well with the early sleep schedule. Stimulant drugs (including caffeine) to keep the person awake during the day may not be necessary. A chief difficulty of treating DSPS is in maintaining an earlier schedule after it has been established. Inevitable events of normal life, such as staying up late for a celebration or having to stay in bed with an illness, tend to reset the person's sleeping schedule to late times again. Adaptation to late sleeping times Long-term success rates of treatment have not been evaluated. However, experienced clinicians acknowledge that DSPS is difficult to treat. Working the evening or night shift, or working at home, make DSPS less of an obstacle for some who have it. Many of these individuals do not think of describing their pattern as a "disorder." Some DSPS individuals nap, even taking four hours of sleep a day and four at night, although long daytime naps tend to promote nighttime sleeplessness. Some DSPS-friendly careers include security work, work in theatre and the media, work in hospitality such as restaurants and hotels, freelance writing, call center work, nursing, and taxi or truck driving. Some people with the disorder are unable to adapt to earlier sleeping times, even after many years of treatment. Sleep researchers have proposed that the existence of untreatable cases of DSPS be formally recognized as a "sleep-wake schedule disorder disability". Rehabilitation for DSPS patients includes acceptance of the condition, and choosing a career that allows late sleeping times. In a few schools and universities, students with DSPS have been able to arrange to take exams at times when their concentration is good. DSPS and depression In the DSPS cases reported in the literature, about half of the patients have suffered from clinical depression or other psychological problems. The relationship between DSPS and depression is unclear. The fact that half of DSPS patients are not depressed indicates that DSPS is not merely a symptom of depression. Even in depressed patients, treatment methods such as chronotherapy can be effective without directly treating the depression. According to the ICSD, "Although some degree of psychopathology is present in about half of adult patients with DSPS, there appears to be no particular psychiatric diagnostic category into which these patients fall. Psychopathology is not particularly more common in DSPS patients" compared with others complaining of "insomnia". American Academy of Sleep Medicine International Classification of Sleep Disorders, Revised Edition 2001. It is conceivable that DSPS often has a major role in causing depression, because it can be such a stressful and misunderstood disorder. A direct neurochemical relationship between sleep mechanisms and depression is another possibility. DSPS patients who also suffer from depression should seek treatment for both problems. There is some evidence that effectively treating DSPS can improve the patient's mood and make antidepressants more effective. In addition, treatment for depression can make patients more able to successfully follow DSPS treatments. See also * Insomnia * Sleep inertia * Circadian rhythm * Circadian rhythm sleep disorders * Chronobiology * Seasonal Affective Disorder * Advanced sleep phase syndrome Notes References * * * * External links * Stanford University - Delayed Sleep Phase Syndrome * ClevelandClinic.org - Delayed Sleep Phase Syndrome and Advanced Sleep Phase Syndrome * Center for Environmental Therapeutics - Discusses the use of light therapy, for SAD, nonseasonal depression, and DSPS. You can use the Ask the Doctor forum to have questions answered by clinical and research specialists from Columbia University. There is a self-assessment questionnaire to choose the optimum timing of light therapy for any individual. * DSPSinfo.org - Written by and for people with DSPS *Niteowl mailing list: an active support group for people with DSPS, and their families, since 1995. * Sleep Discrimination - Night People, the Overlooked Minority Category:Sleep disorders Category:Circadian rhythms Category:Syndromes